

PBMs are telling the Trump administration that disclosing drug prices is illegal. Employers are begging for the data. With $10,000-per-day fines on the table and 136 million Americans caught in the middle, the ugliest fight in healthcare is just getting started.
Imagine you hired a financial advisor, and when you asked how much they were charging you, they said: "That's illegal to tell you."
That's essentially what pharmacy benefit managers (PBMs) are telling the federal government right now. The Trump administration wants PBMs to reveal how much they make on your prescriptions. PBMs say the whole idea is against the law. Businesses, meanwhile, are practically begging for the information. Welcome to the messiest breakup in healthcare.
PBMs are the middlemen of the drug world. They sit between your employer, your insurance company, the pharmacy, and the drugmaker, negotiating prices and pocketing fees at every step. The three biggest players (CVS Caremark, Express Scripts, and OptumRx) control roughly 80% of the market. Think of them as the ticket scalpers of pharmaceuticals: they don't make the drug, they don't prescribe the drug, but they take a cut every time one changes hands.
In January, the Department of Labor proposed a rule that would force PBMs to open the books. The mandate would require them to disclose drug pricing data, rebates, fees, and compensation to the employers who hire them. It would also make it easier for those employers to audit PBM practices. For the roughly 100 million Americans covered by self-insured employer health plans, this could finally pull back the curtain on where their prescription dollars actually go.
PBMs responded the way you'd expect someone to respond when you ask to see their browser history: they panicked.
The public comment period on the proposed rule closed recently, and PBMs did not go quietly. They submitted comment letters opposing the transparency requirements, arguing the disclosures exceed what's needed under ERISA (the federal law governing employee benefit plans). Their core argument? Forcing per-drug pricing reveals is "not necessary" for plan oversight and would overwhelm employers with data they can't use.
It's worth noting that PBMs have a long history of using ERISA as a legal shield. They've invoked it repeatedly to dodge state-level regulations, and the strategy has worked often enough to keep it in the playbook.

Merck's islatravir nearly died after alarming safety signals forced the FDA to halt clinical trials. Now it's the backbone of Idvynso, the first two-drug HIV regimen that ditches the most popular drug class in the field. The comeback story is worth reading.


Join thousands of biotech professionals who start their day with our free, daily briefing.
And the PBMs aren't alone. Drug companies, despite loving the idea of someone else getting scrutinized, also quietly prefer to keep their own pricing data under wraps. It's one of those rare moments where pharma and PBMs are on the same side of the barricade, even if they got there for different reasons.
While PBMs are lawyering up, the people who actually pay the bills are cheering.
Businesses and employer groups see the transparency mandate as long overdue. Mark Cuban's pharmacy venture has been vocal about holding middlemen accountable, and the sentiment runs deep among self-insured employers who've spent years writing enormous checks without truly understanding what they're paying for. Taxpayer advocates have piled on too, pointing out that the current system doesn't give employers appropriate access to the most competitive prices in the market.
The math explains why employers are frustrated. The three biggest PBMs control about eight out of every ten prescriptions processed in this country. When you have that kind of market dominance and zero obligation to show your work, the power imbalance is staggering.
This isn't just a polite suggestion from the government. The transparency requirements come with real consequences.
PBMs that fail to comply face penalties of up to $10,000 per violation, per day. Ryan Temme of Groom Law Group emphasized the scale: failures across multiple business lines could yield "very large numbers very quickly." That's not a parking ticket; that's an existential threat to noncompliant operators.
The rule would require PBMs to provide 30-day pre-contract compensation estimates, followed by semiannual reports of actual figures. Any PBM-linked provider above certain compensation thresholds gets pulled into the disclosure net. Amber Rivers, a Groom principal and former DOL official, noted the rule's broad scope, pointing out that it captures affiliated PBM services across the board.
The DOL proposal doesn't exist in a vacuum. It's one piece of a broader administration offensive against PBM opacity.
In February 2026, President Trump signed H.R. 7148, the Consolidated Appropriations Act, 2026. The law targets the 160 million Americans with employer-sponsored insurance. Separately, the administration launched TrumpRx.gov, giving patients access to most-favored-nation pricing on 40 popular branded medications.
Starting with plan years beginning on or after January 1, 2029, PBMs will have to pass through 100% of rebates, fees, and discounts to plans and insurers on a quarterly basis. That effectively kills spread pricing, the practice where PBMs charge an employer one price and pay the pharmacy a lower one, pocketing the difference. It's like finding out your real estate agent was buying houses for $300,000 and telling you they cost $350,000.
State legislatures are piling on too. Virginia's S.B. 669, with certain provisions effective July 1, 2027 and delinking provisions effective in 2028, adds its own pass-through and fee-only requirements. A patchwork of state laws is creating a regulatory squeeze from both directions.
The legal fight is far from settled. A federal court recently blocked Arkansas's PBM ownership law on constitutional grounds, which gives the industry some reason to believe courts might be sympathetic. PCMA's opposition to the DOL rule could tie things up for months or years.
But the political winds are blowing hard against PBMs. Bipartisan support for transparency, combined with employer frustration and state-level momentum, makes this a difficult tide to fight. Even state attorneys general, including Georgia's Chris Carr, have backed the DOL rule and urged the federal government not to preempt tougher state laws.
PCMA's CEO David Marin has tried to redirect the conversation, highlighting the need for broader supply chain transparency. It's a reasonable point, and it reveals the deeper tension: everyone in the pharmaceutical supply chain wants the spotlight on someone else.
For now, the PBMs are betting that the courts will save them. Employers are betting that sunlight really is the best disinfectant. And somewhere in the middle, the roughly 155 million people covered by employer health plans are just hoping their next prescription doesn't cost as much as a car payment.
Two former Sage Therapeutics leaders just launched a brain-focused biotech with $106 million and four clinical-stage drugs. In a therapeutic area where 85% of drugs fail, they're betting their track record (and two FDA approvals) can beat the odds.